a care plan is a determination of a person's nursing problems and strategies to do something about them. a care plan can be done for a healthy person as well as for someone who is ill.
a diagnosis is based on the assessment data you have collected on the patient. i went through your post and made of list of the assessment data and this is what i found and put in maslow's order of priority along with a few questions i had:
- inadequate fluid intake - what is "inadequate"? describe it.
- decreased hgb and hct - the significance of decreased hgb and hct is blood loss or dehydration. which is it? both conditions have other symptoms that accompany them.
- nausea - this is a symptom. what is the underlying cause of this nausea? was there vomiting with it?
- not having a bowel movement for 5 days postoperatively
- changes in bowel habits - do you mean not having a bm for 5 days? or, are they having loose stools?
- gastric pain - is the patient getting the opioids for this gastric pain or for incisional pain? is the incision near the stomach? i had colon surgery and the incision is very close to where a previous surgery on my stomach was. so, which pain is being referred to and treated? does it matter?
- increased wbcs - how high are we talking about?
if you follow the steps of the nursing process (step #1 is assessment; step #2 is determining the problem or diagnosing the nursing problem; step #3 is planning), then from that list the correct nursing diagnoses in priority order would be:
- deficient fluid volume r/t fluid volume loss aeb decreased hgb and hct
- constipation r/t inadequate fluid intake and use of opioid analgesics aeb no bowel movement for 5 days.
- acute pain r/t surgical intervention and aeb patient report of gastric (abdominal?) pain
- ineffective protection r/t surgical intervention and abnormal blood profiles (increased wbcs and decreased hgb and hct)
- - - - - - - - - - - - - - - constipation related to use of opoid analgesics and manipulation of bowels during surgery as evidenced by patient not having a bowel movement for 5 days postoperatively.
manipulation of bowels during surgery causes an ileus during which the bowel would be empty. the symptoms of an ileus would cause abdominal pain, nausea and vomiting long before there would ever be any constipation. it is treated by keeping the patient npo, sometimes inserting an ng tube and maintaining continuous or intermittent suction to remove secretions that would irritate the gastric mucosa and cause the patient to become nauseated and eventually vomit. the abdominal pain, nausea and vomit would continue and escalate if left untreated. manipulation of bowels during surgery is not an appropriate related factor to use with this diagnosis.risk for deficient fluid volume r/t inadequate fluid intake secondary to nausea.
if the patient is this nauseated use the nursing diagnosis of nausea. as i mentioned above, inadequate is too vague a description. do the work and show that you assessed this patient's intake.